06050102 CITY OF CUPERTINO �r
BUILDING DIVISION � TQ� � � *
PERMIT
BUILDING ADDRESS: O AKI KO LEWIS PERMIT NO.06050102
1169 ELMSFORD DR
PERMIT ISSUE DATE
OWNER'S NAME:
JOHNY AKIKO LEWIS 10/04/2006
SANITARY NO. CONTROL NO.
JE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER:
BLDG ELECT PLUMB MECH
0 0
1 o p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
?Z withlforcnndeffecDivision3ofdteStrsinessandProfessions Code,and mylicense is ADD 7021 KITCHEN MASTERBATH REMODEL INTERIOR
a=y in full Cores and effect r r
z License Class Lien KITCHEN/DINING RETAINING WALL, TERRACE, SKYLIGHTS
l
an Date Contractor
ARCHrl Et-I'S DECLARATION
2 cd—� I understand my plans shall be used as public records
)yU
inLicensed Professional
�0� OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
<Im ff which requires a permit to construct,alter,improve,demolish,or repair any structure
i r prior to its issuance,also requires the applicant for such permit to file a signed statementFloor Area Val$ ibl0 4 8 7
Sq._ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Ft.
F- (commencing with Scction 7000)of Division 3 of the Business and Professions Code)or \`J c)11
L) that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 tP J*T
.Vurnlyr 0 0 Occupancy Type
not more than five hundred dollars($500). 0
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,die owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec B&P C for this reason
Owner D.,X#
16
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Conscnt to self-insure for Worker's compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workcfs Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to becofflo subject to the Workcrs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLI ANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
7_2 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W ALender's Name
a z Lender's Address
U Q 1 certify that I have read this application and state that the above information is
(t, H correct.I agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
1Z liabilities,judgments•costs and expenses which may in any way accrue against said City
U,Z in consequence of the granting of this permit. Date
►'u APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULAT NS.
� Re-roofs
Si ',um IApplicandContractor Date Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE yp
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have tenant,that it is my responsibility to notify the occupant of the
requirements w asstl prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent Date